????????????????????????????????????????????????????

NO-SUICIDE CONTRACTS: AN OVERVIEW

AND RECOMMENDATIONS
????????????????????????????????????????????????????
LILLIAN M. RANGE, CATHERINE CAMPBELL, STACEY H. KOVAC,
MICHELLE MARION-JONES, HOLLYALDRIDGE, STEPHEN KOGOS,
ANDYOLANDACRUMP
The University of Southern Mississippi, Hattiesburg, Mississipi
No-suicide contracts, in their various forms, can deepen commitment to a positive action,
strengthen the therapeutic alliance, facilitate communication, lower anxiety, aid assess-
ment, and document precautions. Conversely, they can angeror inhibit the client, introduce
coercion into therapy, be used disingenuously, and induce false security in the clinician.
Research on no-suicide contracts (frequency surveys, assessments of behavior after con-
tracting, and opinions of users) has limitations common to naturalistic studies, and is
now ready for more rigorous methods. Mental health professions should be trained to deal
with suicidal individuals, including how to use no-suicide contracts. Good contracts are
specific, individualized, collaborative, positive, context-sensitive, and copied. However,
they are not a thorough assessment, a guarantee against legal liability, nor a substitute for
a caring, sensitive therapeutic interaction. No-suicide contracts are no substitute for sound
clinical judgment.
A contract is an agreement between two or more people (Neufeldt &
Sparks,1990). Psychologists oftenuse contracts as one aspect of treatment
for a variety of problems and disorders. One form of mental=behavioral
health contracting is a no-suicide contract. Although somewhat contro-
versial, no-suicide contracts are widely used by mental health profes-
sionals (Stanford, Goetz, & Bloom, 1994). The following article will
describe various forms of no-suicide contracts, delineate the advantages
and disadvantages of using no-suicide contracts in therapy, examine
Received11August 2000; accepted 30 November 2000.
Portions of this paper were presented at a symposiumat the annual meeting of the Mississippi
Psychological Association, October, 1999, Biloxi, MS.
Address correspondence to Lillian M. Range, Department of Psychology, The University of
Southern Mississippi, Hattiesburg, MS 39406-5025. E-mail: L.range@usm.edu.
51
Death Studies, 26: 51774, 2002
Copyright #2002 Brunner-Routledge
0748-1187/02 $12.00 + .00
empirical research on no-suicide contracts, and make research, training,
and clinical recommendations.
Description
A no-suicide contract (also called a no-harm contract, life-maintenance
agreement, or commitment for safety) entails an explicit statement of no
harm and a specific time frame. The time frame is typically as short as a
few hours or as long as a few days, until the next therapy or crisis inter-
vention session. The no-suicide contract also contains contingencies in
case the client becomes unable to keep the agreement. Typically, both
client and therapist keep a copy. In general, no-suicide contracts, like
all behavioral contracts, involve negotiating terms in order to form an
agreement or contract. Both the therapist and client should be accoun-
table for the terms.
The wording of no-suicide contracts varies with individual clients. For
example, no-suicide contracts for adults are typically longer and more
complex than those for children. (See Appendix A for a contract for
adults used at the University of Southern Mississippis Counseling Cen-
ter.) The contract includes up to three individual preferences of action if
clients feel that they may harm themselves or others. Also, the contract
asks clients to agree to admit themselves to the emergency room as an-
other plan of action. This example illustrates the way a contract is cur-
rently used.
Like other behavioral contracts, no-suicide contracts for children
should be developmentally appropriate. An age-based contract uses
age-appropriate language and simplified statements regarding options
for assistance. The format varies slightly between the age groups, but
the fundamental principles throughout are that the childs goal is to live
and become happier, that there are people available if the child believes
that s=he may harm herself=himself or others, and that the counselor
agrees to assist in any way possible. The contract reminds children that
despite their feelings of helplessness, they can seek assistance from a car-
ing and responsible adult. Atheme throughout the contracts is empow-
ering children to help themselves. One example of empowerment is to
ask the child to complete the spaces on whom to contact in time of need
(Davidson & Range, 2000). Appendices B, C, and Dcontainexamples of
contracts for children at various ages.
52 L. M. Range et al.
Another option for children is the school-based contract (see Appen-
dix E). General enough to be used in elementary through high school,
this contract identifies the child as a student of the particular school
and provides a name and phone number of the school counselor. This
agreement also encourages the student to contact a crisis hotline if the
counselor is unavailable (Poland,1989). The 24-hour hotline can guaran-
tee that the child will be able to reach a concerned adult even if parents
and peers are unavailable.
Clinicians should not feel constrained by the use of a``conventional
agreement if it does not seem appropriate for the particular client. One
option that is often used is for the client and clinician to collaborate on a
personalized no-suicide agreement. The negotiation process, as well as
the personal nature of the agreement, can provide a feeling of accom-
plishment and self-fulfillment for the client, as well as a visual plan that
is tailored to the clients personal issues.
Advantages and Disadvantages inTherapy
No-suicide contracts can have advantages that could be classified in be-
havioral, interpersonal, intrapersonal, assessment, and administrative
terms. Likewise, they can have disadvantages that could be classified in
the same way.
Advantages
Behaviorally, no-suicide contracts help the client commit to a course of
action that is inconsistent with suicide (Brent, 1997). Because suicidal
ideation is often impulsive, a contract may provide the immediate con-
trol that clients need (McBrien, 1983). Further, no-suicide contracts can
establish contingencies for specific behaviors (McLean & Taylor, 1994).
In the formulation of the no-suicide contract, the client and therapist
often review what specific steps the client wouldtake if the same difficul-
ties that led to the suicidal crisis would resurface, and make alternative
coping plans (Brent,1997). Hence, no-suicide contracts behaviorally help
clients commit to positive action.
Interpersonally, no-suicide contracts can help to initiate and establish
a therapeutic alliance (Drew,1999; Stanford et al., 1994), and can under-
score the realistic need for the patients active collaboration in treatment
53 No-Suicide Contracts
(Miller, 1990). Clients who are at risk for suicide may believe that the
therapist who asks them to sign a no-suicide contract is genuinely con-
cerned about their safety. Thus, the no-suicide agreement may help cli-
ents view the therapist as empathic (Miller, 1999). Establishing a
common goal may be useful in strengthening the relationship between
the therapist and client, which, in turn, may lead to positive outcomes in
therapy (Sills,1997).
Also, the no-suicide contract can help both client and therapist estab-
lish short-term goals that are attainable. For example, the client who
calls the crisis hotline five times during one week could set a goal of call-
ing onlyonce during the following week. Thus, the no-suicide agreement
can help the suicidal patient postpone suicide until after a crisis has
passed. After coping successfully with the crisis, the client may realize
that suicide is not the only option.
Further, no-suicide contracts may also open up communication be-
tween the client and therapist on an issue that is viewed by many as
taboo. Making a specific agreement could help clients feel comfortable
in describing their own urges and intentions in regards to suicide. Also,
after negotiating a no-suicide contract, clients may feel a sense of relief
that the therapist brought up the issue of suicide and may feel more com-
fortable working on other issues intherapy as well (Rudestam,1986). De-
veloping a specific no-suicide agreement could open the doors to deeper
communication than previously occurred in therapy.
Intrapersonally, no-suicide contracts may also reduce both clients
and therapists anxiety. Clients who use a no-suicide contract may feel
in control of their suicidal thoughts and behaviors because they set their
own terms. This feeling of control with suicidal thoughts may extend
further as clients take responsibility for their treatment in therapy
(Miller, 1999). Showing empathy and genuine concern for the client
may help them with their suicidal thoughts and feelings, and an actual
contract can symbolize in a concrete way this concern and this ongoing
relationship with the therapist. Therapists who use a no-suicide contract
may find that it helps to reduce therapist anxiety as well (Stanfordet al.,
1994). Thus, no-suicide contracts may increase client autonomy, symbo-
lize therapist concern, and decrease anxiety for both.
An assessment advantage of no-suicide contracts is that they can be
used to evaluate suicide risk. Reluctance to sign a no-suicide contract
may raise a``red flag for the therapist. A client who is unable to sign a
no-suicide contract may need to be hospitalized. Indeed, no-suicide
54 L. M. Range et al.
contracts were first reported as a quick assessment method (Drye,
Goulding, & Goulding, 1973), and clinicians recommend their use as an
exquisitely sensitive assessment tool (Shea,1999). Patients who seemcon-
fident about the agreement, maintain eye contact, and show no hesi-
tancy, qualifications, or other signs of ambivalence or deceit are at low
suicide risk (Shea,1999); however, patients who object or make qualifica-
tions are at relatively higher suicide risk (Drye et al., 1973). Inasmuch as
no-suicide contracts involve active discussion with the client, they could
be more useful in assessing suicidal risk than objective paper-and-pencil
inventories that allow for no interactive communication (Rudestam,
1986). No-suicide contracts may allow the therapist to assess suicidal risk
in a way that is different from objective suicide inventories.
An administrative advantage of no-suicide contracts is to serve as
partial documentation of the therapists efforts to contain suicide risk,
and are more compelling than a global statement in a therapy note.
Although there are no guarantees against lawsuits, the best course is ``to
provide good care, make the best decisions possible, anddocument these
activities to the best of ones ability (Clark, 1998, p. 92). A no-suicide
contract could be part of this documentation.
Disadvantages
No-suicide contracts have disadvantages that parallel their advantages.
A therapeutic disadvantage is that clients may mistakenly believe that
the therapists only concern is the contract or the potential for legal
action, rather than any genuine regard for the client. In this case, cli-
ents could view the no-suicide contract as a coping mechanism for the
therapist rather than as a clinical intervention tool for the client
(Miller, 1999). Having the no-suicide contract in a standardized,
inflexible form could reinforce this view. Thus, no-suicide contracts
could lead clients to doubt the therapists concern for them. This
doubt, whether reasonable or unreasonable, could interfere with the
therapeutic alliance.
Additionally, clients who are reluctant to change their behavior, even
if it is self-destructive, may become angry when the therapist asks them
to sign a no-suicide contract. The anger could create a chance for the
therapist andthe client to discuss openly the clients anger but could also
increase distance between client and therapist and reduce the therapeu-
tic alliance. Further, asking for a no-suicide contract could even set the
55 No-Suicide Contracts
stage for counterproductive manipulation and theatrical standoffs
(Shea, 1999). Thus, no-suicide contracts could be seen as intrusive and
therefore weaken the relationship between the therapist and the client.
Further, no-suicide contracts may also inhibit clients from discussing
their suicidal thoughts with the therapist. Clients could believe that dis-
cussing their suicidal ideations violates the terms of the no-suicide con-
tract (Miller,1999). In addition, clients may feel that they are a failure if
they continue to have suicidal thoughts. So, instead of disclosing these
thoughts to the therapist, clients keepthe thoughts to themselves, becom-
ing increasingly isolated and despondent. In this case, the therapist may
mistakenly believe that the client is no longer suicidal (Miller, 1999), a
potentially dangerous situation.
Also, no-suicide contracts could introduce an element of coercion into
the therapeutic relationship (Miller, 1990). Clients may feel that they
must complete the no-suicide contract in order to continue receiving ser-
vices from the therapist. This perception could create a power differen-
tial between the therapist and the client that interferes with therapy.
Indeed, some experts posit that the threat of suicide makes a true thera-
peutic contract impossible because the central feature of that contract,
the element of patient choice, may be restricted or removed (Miller,
1999).
A final therapeutic disadvantage is that the therapist might actually
focus on the contract to the detriment of the therapeutic relationship.
The no-suicide contract alone is a shallow substitute for complex, em-
pathic interpersonal involvement (Miller,1990). If the therapist confines
the largest portion of therapy with a suicidal patient to obtaining a no-
suicide contract, other aspects of the communication couldbe negatively
affected (Miller, 1999). Further, persons lacking adequate training may
over-rely on no-suicide contracts or use them disingenuously. For exam-
ple, an aide with little or no connection to the suicidal person could ask
for a signature on a preprinted form, but this procedure may have little
or no impact on the persons future behavior. In addition, if no-suicide
contracts reduce the therapists level of anxiety, the therapist could
develop a false sense of security (Callahan,1996). Fromthe clients point
of view or the therapists point of view, no-suicide contracts might actu-
ally interfere with therapy.
An assessment disadvantage of no-suicide contracts is that they may
mistakenly convey the ideato clinicians that they have assessed suicidal-
ity. No-suicide contracts are static and easily broken and have no
56 L. M. Range et al.
predictive validity (Berman & Jobes, 1994). A no-suicide contract is no
substitute for thorough assessment.
An administrative disadvantage of no-suicide contracts is that they
may mistakenly convey the idea to clinicians that they are protected in
case of a malpractice lawsuit. No-suicide contracts are not legal docu-
ments; they are not legally binding (Miller, 1999; Stanford et al., 1994).
No-suicide contracts cannot be solely used in a court of law to demon-
strate adequate assessment or management of suicidal risk (Drew, 1999;
Miller, 1999). Therapists must decide how they are going to handle a si-
tuation if a client refuses to complete a no-suicide contract, a scenario
that is likely to occur at some point in a therapists career. Even if a per-
son refuses to sign a no-suicide contract, the therapist must protect him
or her from self-injury. Therefore, from a legal perspective, the no-
suicide contract may not be useful because the therapist has a legal obli-
gation to ensure the clients safety.
No suicide contracts may have advantages or disadvantages depend-
ing on the client, the therapist, andtheir relationship. Although havinga
person sign a contract may be helpful, it could be that those who are
most helped by the contract are also those who are most helped by em-
pathy, the chance toventilate their problems, or the practical advice that
the therapist gives during the crisis. No-suicide contracts are no substi-
tute for good clinical judgment.
Empirical Research
Although no-suicide contracts are frequently cited in psychological, psy-
chiatric, and nursing literature, research on these contracts is sparse.
One reason for this lack of research is that suicide is a lowbase-rate phe-
nomenon, so interventions to prevent it are hard to prove or disprove
(Mishara & Daigle, 1997). The majority of suicidal patients, even those
who are highly suicidal, do not commit suicide. Another reason is that
the most experimentally sound research design would be to identify a
large group of suicidal individuals, obtain a no-suicide contract with a
randomly selected half of them, and measure the suicide rate in the
whole group. To date, this type of design has not been conducted. There-
fore, no-suicide agreements are generally recommended by many sui-
cide experts but are rarely studied empirically. Indeed, their use is
based more on impressions than data (Miller, 1999). The research that
57 No-Suicide Contracts
does exist falls into three general categories: frequency surveys, research
on the impact of no-suicide contracts on suicidal behavior, and opinions
of users.
Frequency Surveys
Inthe original publication, Drye et al. (1973) reportedtraining clinicians
to make no-suicide contracts, estimating that they made 600 no-suicide
contracts over five years. They surveyed 31trainees, who reported using
no-suicide agreements with 609 suicidal patients, 266 of whom were
``seriously suicidal (Drye et al., 1973). This original work indicated that
clinicians used no-suicide contracts after training but did not assess
whether they used no-suicide contracts before training.
More recent and more systematic surveys indicate that most mental
health professionals use no-suicide contracts. A survey of 84 directors of
psychiatric hospitals and units (82% response rate) defined suicidal be-
havior as deliberate self-harm with suicidal intent. The survey did not
limit suicidal behavior on the basis of lethality, but excluded self-mutilat-
ing behavior that had purposes other than death (e.g., to relieve anxiety,
or seek attention). The majority of these administrators (n = 66, 79%)
reported using no-suicide contracts, which were typically given by
nurses and typically used with patients who talked, threatened, or at-
tempted suicide. These directors used a variety of types of no-suicide
contracts, including handwritten ( n = 48, 74%), verbal ( n = 47, 72%),
and preprinted forms ( n = 10, 15%) (Drew, 1999). Thus, administrators
report that no-suicide contracts are a common professional experience.
Head nurses report the same frequency of use. In a survey of head
nurses of psychiatric inpatient units, more than 80% saidthat their units
used no-suicide contracts. Further, these head nurses thought these con-
tracts were useful (Green &Grindel,1996). Administrators of psychiatric
hospitals, and head nurses agree that no-suicide contracts are common.
This experience comes early in a mental health career. In one survey
of 112 clinicians, by the completion of residency or internship, 79% of
psychiatrists and 72% of psychologists at Harvard Medical School re-
ported that they had witnessed the use of no-suicide contracts. Addition-
ally,77% of the psychiatrists and 75%of the psychologists statedthat the
contracts were recommended at their place of employment; 86% of psy-
chiatrists and 71% of the psychologists regularly used them; and 61% of
the psychiatrists and 71% of the psychologists used them at least half of
58 L. M. Range et al.
the time with suicidal individuals. Also, 61% of psychiatrists and 71% of
psychologists reported no formal training, which was defined as one or
more lectures focusing on the history and use of no-suicide contracts,
their indications, risks, benefits, and contraindications (Miller, Jacobs,
& Gutheil, 1998). Thus, most mental health professionals have some ex-
perience with no-suicide contracts, experience that begins early in their
career, and comes in the absence of formal training.
Impact on Behavior
The original research on no-suicide contracts evaluated actual behavior
of patients, who were from diverse settings including hospitals, clinics,
private offices, andcommunityagencies. Clinicians reportedthat during
the no-suicide timespan, with clients that they judged to be seriously sui-
cidal, one patient killed herself outside the time period, one died froman
overdose, one died from an ambiguous accident, and one seriously at-
tempted suicide. In contrast, these clinicians reported 20 suicidal deaths
or serious attempts in their practice when they had not used no-suicide
contracts (Drye et al.,1973). This first empirical work on no-suicide con-
tracts contains several methodological flaws: (1) no statistical analyses
were performed on these data; (2) the sizes of the two groups are not
given, so there is no way to compare rates; (3) the time frame was differ-
ent; (4) the authors did not specify the criteria for defining``seriously sui-
cidal; and (5) clinicians memories could have been biased. This first
published empirical investigation of no-suicide contracts was ground-
breaking, but the positive effects were obtained in a flawed design.
Another study of actual behaviors reviewed suicide incidence reports
on a child and adolescent inpatient unit. Most of these youth were diag-
nosed with either conduct disorder, major depression, or dysthymia.
Contracts commonly targeted several different kinds of behaviors: (a)
unauthorized running away from the unit or activities; (b) suicide at-
tempts or suicidal talk; (c) physical aggression; and (d) sexual acting
out. Among 360 children who were treated at the hospital before con-
tracts were used, 58 children (16.1%) were involved in some sort of inci-
dent. Among 570 children who were treated using contracting for
change, 8 children (1.4%) were involved in some sort of incident (Jones,
OBrien, & McMahon, 1993). This report was also promising and cor-
rected for some of the previous methodological problems, including
reporting rates and correcting for the possibility of retrospective bias.
59 No-Suicide Contracts
However, the data was from charts, the time frames were different, and
staff changes occurred between the no-contracting and contracting per-
iods. Further, there was no randomassignment. These factors could have
a profound impact on the data.
Research on no-suicide contracts need not be limited to in-person si-
tuations. In a unique approach to studying whether no-suicide contracts
change behavior, researchers listened unobtrusively to 617 callers at two
suicide prevention centers where telephone volunteers had been trained
to contract with the caller. The no-suicide contract involved refraining
from suicide, engaging in a follow-up activity to develop a long-term res-
olution of a suicidal crisis, and making a follow-up contract with the
center. In the majority of calls (68%), the telephone clinician obtained
a no-suicide contract. Researchers classifiedthose who failed to call back
in a follow-up as non-compliant. Using this conservative definition, the
majority of callers upheldthe contracts (54%); some did not make a con-
tract (31%); a minority (14%) failed to keep the contract; and 1% of
callers attempted suicide after calling (Mishara & Daigle, 1997). These
resultsthough limited by the high number lost to follow-up, potential
biases in retrospective recall, and absence of a control groupsuggest
that no-suicide contracts used on the telephone may change actual
behavior.
Research on the impact of no-suicide contracts on actual behavior has
beenpromising, though infrequent and flawed, limitations that might be
expected from naturalistic research on low-incidence behavior. How-
ever, the field is nowready for more rigorous research including random
assignment, well-matched control groups, and true experimental ma-
nipulations.
Opinions of Users
An important way to examine whether no-suicide contracts actually
work would be to ask those who use them. Users could include mental
health professionals, other professionals who might be called upon to
use no-suicide contracts, or peers of suicidal individuals. Also, users
could include patients who are actually suicidal.
Whenasked a hypothetical question, practicing clinicians moderately
favor no-suicide contracts. When surveyed, licensed psychologists were
optimistic about no-suicide contracts with moderately suicidal adults
and adolescents but were neutral to slightly pessimistic regarding their
60 L. M. Range et al.
use with children ages 6711years and 9712 years, perhaps because chil-
dren of this age are limited in cognitive ability. Further, these clinicians
viewed no-suicide contracts as helpful with moderately suicidal patients,
but only slightly helpful with mildly or severely suicidal patients
(Davidson, Wagner, & Range, 1995). Overall, these clinicians viewed
no-suicide contracts as more helpful than harmful, though their positive
feelings about no-suicide contracts were tenuous.
When askedabout a specific situation, however, mental health profes-
sionals favor no-suicide contracts. In one survey, 368 clinicians who
worked with children indicated that they were mildly to moderately in
favor of written no-suicide agreements regardless of the reading level of
the agreement. These practicing professionals saw no-suicide agree-
ments as more appropriate whenthe child in the vignette had no history
of academic problems, was relatively older (9 to11or 12 to17) rather than
6 years of age, and relatively free of academic problems (Davidson &
Range, 2000). Though clinicians had only moderate faith inthe effective-
ness of such agreements, they apparently believed that they would not
hurt child clients. When given a specific situation, experienced profes-
sionals saw no-suicide agreements as moderately to strongly appropri-
ate, though only mildly to moderately effective.
Are the opinions of mental health professionals the same as the opi-
nions of other professionals, such as educators? It is reasonable to ex-
pect that teachers will face suicidal students at some time during their
careers (Davidson & Range, 1997). Educators need to know the danger
signals of suicide and how to use appropriate intervention techniques
(McBrien, 1983), one of which could be a no-suicide contract. In one
study, 63 practice teachers reported that they would take direct action
by calling the parents of a suicidal youth, escorting the youth to the
school counselor, and staying with the youth until another adult ar-
rived. They were neutral about whether they would use a written or
verbal no-suicide agreement. These findings were true regardless of
the age of the student or the level of risk (Davidson & Range, 1997).
Thus, although these teachers-in-training expected to act when a stu-
dent was suicidal, they were neutral about whether this action would
be to use a no-suicide contract.
Teachers less-than-positive attitude may be due to an absence of
training in how to deal with suicidal youth during their careers. How-
ever, they are responsive to training in this area. After one in-service
training module about suicide warning signs and no-suicide contracts,
61 No-Suicide Contracts
teachers were more certainthat they wouldactively intervene when con-
fronted with a suicidal student. Interventions that they endorsed in-
cluded physically escorting the suicidal youth to the counselors office
and calling his or her parents. They changed from uncertain=slightly
likely to highly likely to use a written or verbal no-suicide agreement.
This shift from neutral to proactive is important because teachers may
be the first or only adults to have an opportunity to interact with a suici-
dal youth (Davidson & Range, 1999). Thus, teachers may be initially
neutral to slightly positive about no-suicide agreements, but after brief
in-service training become strongly positive.
In addition to clinicians and teachers as potential users of no-suicide
contracts, still another potential user is the peer of a suicidal individual.
Peers are often the first person contacted by a suicidal individual. In a
survey of 396 students from 19 health classes at two southwestern high
schools, some had been taught to use no-suicide agreements but few had
ever called a crisis hotline or contacted a counseling service. However,
about 50% said that they would share suicidal thoughts with a friend.
Further, these students were responsive to training in no-suicide con-
tracts. At one and seven weeks, those who received training were more
likely than others to say that they would obtain a no-suicide contract
from a suicidal peer (Hennig, Crabtree, & Baum, 1998). Thus, peers
as well as professionals are responsive to training about no-suicide
contracts.
A different approach to assessing users would be to ask suicidal indi-
viduals themselves. One such project accomplished this objective.
Among 39 psychiatrically hospitalized children (mean age = 13.3 years),
researchers defined suicidal behavior as suicide attempts, suicidal talk,
and self-mutilation including cutting, scratching, tattooing, and writing
on oneself (Jones & OBrien,1990). The treatment involved developing a
writtencontingencycontract inwhichchildren receivedprivileges based
on meeting the terms of the behavioral agreement. Childrenused a vari-
ety of contracts, including but not limited to no-suicide contracts. Then,
they completed a 32-item questionnaire assessing the efficacy of various
treatments they received, including contracting. They rated the con-
tracting ``very high in helping them change their behaviors but were
only moderately interested in continuing to contract after discharge
(Jones & OBrien, 1990). A limitation of this study was that no informa-
tion was provided on whether childrens responses to the questionnaire
were confidential or anonymous, so the effects of social desirability on
62 L. M. Range et al.
their ratings are unknown. In addition, there was no concurrent collec-
tion of data on the incidence of suicidal behavior (Drew, 1999). Also, this
naturalistic study failed to include randomassignment. Perhaps only the
healthiest children were willing or able to use no-suicide contracts.
Furthermore, the hospital staff changed over time. Nevertheless, this re-
search showed that hospitalized inpatient children had a positive atti-
tude toward no-suicide contracts as part of treatment. This study was
unique in that it ascertained the attitudes of potentially suicidal indivi-
duals, rather than those who deal with them.
Research on no-suicide contracts has surveyed frequency, compared
actual behavior with and without no-suicide contracts, and assessed the
opinions of users. Each approach has merits as well as limitations. Fre-
quency surveys can reveal the current standard of care. Actual deaths
are a powerful index of whether no-suicide contracts work, but few ac-
tual deaths occur in a low-base-rate phenomenon such as suicide; some
deaths are ambiguous, and researchers are sometimes unable to ascer-
tain cause of death, or even that a person died. Actual attempts are also
a powerful index of whether no-suicide contracts work, but attempts are
hard to measure because patients may misreport, be lost to follow-up, or
provide answers biased by social desirability or other distortions. Opi-
nions of users are also a valuable index of effectiveness, but opinions
could be biased by their retrospective nature, potential for self-serving
or other biases, or by the fact that the questions are hypothetical. Most
research on opinions has examined the opinions of professionals, with a
fewexceptions (Jones et al.,1993; Mishara & Daigle,1997) very little has
assessed the opinions of potentially suicidal individuals who used no-
suicide contracts.
Recommendations
There is a paucity of literature on no-suicide contracts. More research is
necessary on howno-suicide contracts affect actual rates of attempts and
completions, and opinions of users. Also, mental health training on sui-
cide is sparse. More is needed, particularly on how and when to use no-
suicide contracts. Despite these limitations, clinical recommendations
about the use of no-suicide contracts can be gleaned from the clinical
and research literature.
63 No-Suicide Contracts
Research
Research that examines actual death rates has great value, though the
low base rate of suicidal behavior makes such research difficult.
Further, because no-suicide contracts may be helpful, no one has yet
designed a research project that involved deliberately withholding
them from suicidal individuals. An alternative paradigm would be to
conduct a prospective study of a large number of suicidal individuals,
assessing attempts as well as completions. For example, one could make
a no-suicide contract part of the check-out procedure of a psychiatric
hospital, comparing the suicide rate among those who had this addi-
tional step with the rate among those who had a routine discharge
procedure.
Assessing callers to a telephone hotline (i.e., Mishara & Daigle,
1997) is a novel approach. We recommend this type of creativity in re-
search design involving no-suicide contracts. For example, one could
deliberately obtain no-suicide contracts with one group of callers but
not another, then query them later about whether the intervention
was helpful.
Research on suicidal people who used no-suicide contracts has great
value. Only one nursing study (Jones & OBrien, 1990) has actually
used this procedure. We recommend more research of this type. Fol-
lowing Jones and OBrien, one could assess opinions about a variety
of aspects of treatment, of which no-suicide contracts are one compo-
nent. Also, one could query suicide attempters, asking them if a no-
suicide contract would have deterred the attempt. Alternatively, one
could query clinical inpatients or outpatients about whether or not a
no-suicide contract would make a difference to them. Qualitatively,
one could ask those who had been suicidal what aspects of the contract
helped or hurt, or what they would recommend with regard to no-
suicide contracts.
Training
Most (70%) practicing psychologists (Peruzzi & Bongar,1999) and psy-
chologytrainees (55%, Kleespies, Penk, &Forsyth,1993) report some for-
mal training inthe study of suicide, though it is typically only one or two
lectures (Kleespies et al.,1993) and could be described as cursory (Nei-
meyer, 2000). Training is needed, given that in one survey approximately
64 L. M. Range et al.
97% of psychology trainees reported working with suicidal individuals,
29% had at least one client who attempted suicide, and11% of trainees
hadaclientcommit suicide (Kleespies et al.,1993).
Training in dealing with suicidal individuals shouldbegin early inthe
training program and continue throughout all aspects of the prepara-
toryexperience (Westefeldet al., 2000). One necessarycomponent of this
training should be the use of no-suicide contracts. Training can be pro-
vided formally and informally. At a minimum, training should include
at least one didactic course with content in both suicide and death
(Chemtob, Bauer, Hamada, Pelowski, & Muraoka, 1989). Supplemen-
tary offerings such as workshops, discussion groups, and=or experiential
exercises, optimally led by a multidisciplinary team, could be added to
helptrainees feel comfortable around suicidal persons, as well as the gen-
eral topic of death (Chemtob et al., 1989).
In addition to knowledge, training should focus on values clarifica-
tion and anxiety reduction (Neimeyer, 2000). Toward this end,
readings on the ethics of suicide prevention could be supplemented
with relevant self-exploration exercises. Reflection on shared and
unique concerns in a supportive environment, in combination with
close mentoring and graded exposure to working with highly per-
turbed clients, could support trainees in developing competencies
with suicidal individuals, a very demanding client population
(Neimeyer, 2000). Training in no-suicide contracts should not be left
to happenstance but should be addressed through well-organized, co-
herent training integrated in the core requirements for all mental
health professionals.
This training should be evaluated. Questions with regard to training
include whether some groups might be more responsive than others, and
which components of training are most helpful for which people.
Further, evaluating no-suicide contracts should include a follow-up com-
ponent.
Clinical
Good no-suicide contracts are specific. They begin with a clear state-
ment of the purpose of treatment, a purpose to which both parties mu-
tually agree (Miller, 1990). They are specific and detailed in what
qualifies as a violation of contract and what are the exact definitions of
terms in the contract (Murphy, 1988). The wording of a contract should
65 No-Suicide Contracts
ensure that all parties comprehend the contingencies. (See Appendix F
for a detailed example.)
Good no-suicide contracts are individualized. They provide for alter-
native coping mechanisms (Miller, 1990), and a back-up plan that typi-
cally consists of phone numbers and names of people to call in case the
person can not keep the commitment (Brent, 1997). The back-up plan
might be a telephone crisis line, a hospital emergency room, the thera-
pists beeper, the individuals family or friends, or some combination.
A standardized form may feel coercive to the client and may create a
power differential between the therapist and the client. Therefore, hav-
ing the client write out his or her own contract is desirable.
Some special recommendations are in order for using no-suicide con-
tracts with children. Researchers and practitioners may want to add a
statement about whowill be informed (parents or guardians) if the child
reveals suicidal thoughts or inclinations (Davidson & Range, 2000).
Further, beyond understanding specific words, practitioners should be
very careful to insure that the child fully understands what it means to
promise to refrain from self harm. One way to accomplish this goal
would be to ask the child to repeat back, in his or her own words, what
he or she understands the promise to mean (Davidson & Range, 2000).
A no-suicide agreement is no substitute for interacting with the child,
conveying care and concern, and taking concrete action if needed.
Good contracts are collaborative. In addition to the clinician and the
client, a collaborative approach might also include parents, teachers,
peers, and other involved parties. Active client involvement in the con-
tracting process is responsive to ethical guidelines requiring fully in-
formed consent regarding treatment procedures and goals (Murphy,
1988). Collaborated contracts are much preferred to dictated ones.
Goodcontracts are positive inwording and in reinforcement. Positive
wording might include the agreement to keep oneself safe (Sills, 1997).
Many individuals, such as those with borderline personality disorder,
have experienced rejection, punishment, and emotional, sexual, and=or
physical abuse. Therefore, punishment may simply repeat a familiar pat-
tern. The therapist should reinforce the client for meeting short-term
goals, which may reduce feelings of helplessness (McLean & Taylor,
1994). Therefore, omit penalty clauses from no-suicide contracts.
Good contracts are context-sensitive. The no-suicide contract should
occur within the context of a therapeutic relationship. Realistically, no-
suicide contracts are often necessary on the first visit, when the clinician
66 L. M. Range et al.
has no history with the patient, and little time to forge a relationship.
Nevertheless, some time to hear the patients pain, actively listen to his
or her story, is a solid foundation that will help enable client and clini-
cian to struggle through a suicidal crisis. The no-suicide contract will be
more beneficial after a therapeutic alliance is established than as an in-
itial step. No-suicide contracts are only one step in a therapeutic inter-
vention with a suicidal individual.
One aspect of context that could be overlooked is the suicidal indivi-
duals background. If the suicidal individual is a member of a minority
group and the mental health professional is not, the clinician should as-
certain whether the agreement is meaningful to the person. If religion is
an important aspect of the suicidal individuals life, the clinician should
ascertain how the contract fits with his=her religious beliefs. If the suici-
dal individual has prior experience with behavioral contracting, the
clinician should ascertain whether or not this experience was helpful.
Another aspect of context that could be overlooked is the therapists
frame of mind. The clinicians reaction (i.e., anger, frustration, etc.) to
suicidal patients is very complex and may result in aversive, thoughtless,
irrelevant, cynical, or coercive use of the no-suicide contract (Miller
et al., 1998). Alternately, no-suicide contracts may reduce the clinicians
feelings of helplessness, anger, frustration, and confusion to the point
where he or she is able to use more effective and efficient techniques with
current and future patients (Assey, 1985). Professionals should negotiate
no-suicide contracts when they are in a good frame of mind. Because
suicidal individuals are often very difficult and demanding clients, using
a no-suicide contract should be considered as a sign that the therapist
would benefit from supervision or consultation.
Good no-suicide contracts are limited. Rather than being a forever
promise, no-suicide contracts have a limited time frame, such as until
the next appointment. For an educator, it might be until tomorrow, until
our next meeting together, or until Monday morning. Time-limited
promises are easier to keep than forever promises.
Even good no-suicide contracts are no substitute for thorough assess-
ment. In addition to the clinical interview, a thorough assessment might
include traditional questionnaires, brief screening measures, or non-
traditional instruments. Traditional suicide questionnaires include the
Scale for Suicide Ideation (Beck, Kovacs, & Weissman, 1979), which can
be completed by a clinician, a paraprofessional, or by the suicidal indivi-
dual; the Suicidal Ideation Scale (Rudd, 1989); the Suicide Probability
67 No-Suicide Contracts
Scale (Cull & Gill, 1982); the Reasons for Living Inventory (Linehan,
Goodstein, Nielsen, & Chiles,1983); andthe Suicidal Ideation Question-
naire (Reynolds, 1987), which comes in adult, junior high, and senior
high versions. Brief screening instruments include the Suicide Behaviors
Questionnaire (Cole,1988), which comes in adult (Cole,1988) and child
(Cotton & Range, 1993) versions; and the Suicide Status Form (Jobes,
Jacoby, Cimbolic, & Hustead, 1997). Non-traditional instruments in-
clude Multi-Attitude Suicide Tendency Scale (Orbach et al., 1991); and,
the FairyTales Test (Orbach, Feshbach, Carlson, Glaubman, & Gross,
1983), a projective technique for children. For a review of 20 suicide as-
sessment instruments, see Range and Knott (1997). No-suicide contracts
are no substitute for standardized, validated instruments, andcannot re-
place a clinical interview for assessing suicidality.
Though they provide good documentation of therapist efforts to pre-
vent suicide, no-suicide contracts are no guarantee against lawsuits.
Documentation that avoids shorthand (such as ``patient contracted for
safety) is helpful (Miller, 1999), but the therapist should not be fooled
into thinking that using a no-suicide contract will prevent a malpractice
suit. No-suicide contracts are not legal documents. For this reason, clin-
icians should avoid the word contract in their clinical interactions with
suicidal individuals, choosing instead ``agreement, ``promise, or ``com-
mitment.
Good contracts are copied. The final step in treating suicidal indivi-
duals is to elicit and maintain a commitment to stay alive, avoid suici-
dal behavior, and use problem-solving strategies learned in therapy
(Linehan, 1999). Whether these commitments should be written or not
is a matter of personal preference (Linehan, 1999). If they are written,
however, copies should go to the patient, the therapist, and at times the
family and=or staff (Miller, 1990). Written materials that outline the
nature of treatment, its goals, and the expectation of the patient could
have a beneficial educational effect and may reduce strain (Miller,
1999).
No-suicide contracts that are specific, individualized, collaborative,
positive, context-sensitive, and copied as needed are part of the arma-
mentariumwith which a clinician deals with a suicidal individual. They
are not a thorough assessment, they are not a guarantee against legal
liability, and they are not a substitute for a caring, sensitive therapeutic
interaction. Nevertheless, used respectfully and empathically, they can
be a useful adjunct to treatment for a suicidal individual.
68 L. M. Range et al.
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Appendix A: Actual No-Suicide Contract
I, _______________________________________ _____ agree that I will not do anything that would cause
harm to myself or anyone else, for the following length of time:
____________________________________ ________ .
I realize that Iamresponsible for myown actions, andthat if I feel my
life is becoming too difficult, I agree to do one or more of the following
actions so that there is no harmto myself or others. Call
1. ___________________________________ ________ _ at ____________________________________ ________ ,
or
2. ___________________________________ ________ _ at ____________________________________ ________ ,
or
3. ___________________________________ ________ _ at ____________________________________ ________ ,
or I will go to the emergency room.
___________________________________ ________ _ _____________________________________ _______
Client Signature Date
___________________________________ ________ _ _____________________________________ _______
Witness=Counselor Signature Date
71 No-Suicide Contracts
Appendix B: No-Suicide Agreement
for 6- to 8-Year-Old Child
I, _____________________________________ _______ , will do these things.
1. I want to live a long life and be happy.
2. I will come to counseling to learn how to be happy.
3. While I learn how to be happy, I will not hurt or kill myself. I
know it will take time to learn how to be happy.
4. If I ever want to hurt or kill myself I will tell _____________________________________ _______ or I
will tell _____________________________________ _______ .
5. My counselor, __________________________________ __________ , will help me learn howto be happy.
6. I will do all of these things until ____________________________________________ , when I see my
counselor, ___________________________________ _________ , again.
____________________________________ _______ _ _____________________________________ ______ _
Name Date
____________________________________ _______ _ _____________________________________ ______ _
Witness: Name Date
Appendix C: No-Suicide Agreement for 9711-Year-Old Child
While I am in counseling, I, ___________________________________ _________ , will do these things.
1. I want to live a long life and be happy.
2. When I feel bad and I want to hurt myself or kill myself I can not
be happy. I will come to counseling to learn how to be happy.
3. While I learn how to be happy I will not hurt or kill myself. I
know it will take time to learn how to be happy.
4. If at any time I want to hurt or kill myself, I will tell __________________________________ _________ _
or I will tell ____________________________________________ . If I cannot find ___________________________________________ _ or
____________________________________ _______ _ I will call ____________________________________ _______ _ or __________________________________ __________ .
5. My counselor, ___________________________________ _________ , agrees to work with me to help me
learn how to be happy.
6. I agree to keep this agreement until __________________________________ __________ , when I see my
counselor again.
____________________________________ _______ _ _____________________________________ ______ _
Name Date
____________________________________ _______ _ _____________________________________ ______ _
Witness: Name Date
72 L. M. Range et al.
Appendix D: No-Suicide Contract for12717-Year-Old
Child=Adolescent
As part of mycounseling, I, ____________________________________ ________ , will dothefollowingthings.
1. I agree that one of my major goals is to live a long life with more
happiness than I nowhave.
2. I understand that wanting to hurt myself or kill myself gets in the
way of this goal. I want to learn better things I can do when I feel
bad. I want to find answers to my problems.
3. I understandthat feeling better will take time so I will not hurt or
kill myself between nowand ___________________________________ _________ , when I see my coun-
selor again.
4. If at any time I want to hurt or kill myself I will tell ____________________________________ _______ _
or _____________________________________ _______ . If I cannot find __________________________________ _________ _ or ____________________________________ _______ _
I will call ___________________________________________ _ at ___________________________________________ _ or ___________________________________________ _ at
__________________________________ __________ .
5. My counselor, __________________________________ __________ , will work with me to help me learn
better ways to take care of my problems. My counselor,
__________________________________ __________ , will be available as much as possible if I feel very
upset.
6. I will keep this agreement until it expires or until ___________________________________ _________ ,
when I see my counselor again. My counselor and I can then
make another agreement if we need to.
__________________________________ _________ _ ___________________________________ ________ _
Name Date
__________________________________ _________ _ ___________________________________ ________ _
Witness: Name Date
Appendix E: School-Based No-Suicide Contract
I, ___________________________________________ _ (name) ____________________________________________ , a student at ___________________________________________ _
(school) ______________________ _____________________ _, take the responsibility for my welfare, and
I agree not to harm myself in any way. I understand that if I am having
suicidal thoughts, I agree to call my counselor, ____________________________________ _______ _ (name), at
___________________________________________ _ (phone number). If I cannot reach my counselor, I will
call the crisis hotline at ___________________________________ ________ _ (phone number) or I will tell the
nearest adult and get help for myself.
73 No-Suicide Contracts
Appendix F: Detailed No-Suicide Contract
As a part of my therapy program, I, _____________________________________ _______ , agree to the fol-
lowing terms.
1. I agree that one of my major therapy goals is to live a long life with
more pleasure and less unhappiness than I have now.
2. I understand that becoming suicidal when depressed or upset stands
in the way of achieving this goal, and I therefore would like to over-
come this tendency. I agree to use my therapy to learn better ways to
reduce my emotional distress.
3. Since I understandthat this will take time, I agree in the meantime to
refuse to act on urges to injure or kill myself between this day and
_____________________________________ _______ .
4. If at any time I should feel unable to resist suicidal impulses, Iagree to
call __ __ __ _ _ __ __ __ __ __ __ _ _ ___ _ __ _ _ ___ _ _ __ _ ___ _ __ (name) at _ __ __ __ __ __ __ _ _ __ __ __ __ __ __ _ _ __ __ __ __ __ __ __ _ (number) or
_____________________________________ _______ (number). If this person is unavailable, I agree to call
___________________________________________ _ (name) at ___________________________________________ _ (number) or ___________________________________________ _
(number) or go directly to ___________________________________ ________ _ (hospital or agency) at
_____________________________________ _______ (address).
5. My therapist, ___________________________________ _________ , agrees towork with me in scheduled ses-
sions to help me learn constructive alternatives to self-harm and to be
available as much as is reasonable during times of crisis.
6. I agree to abide by this agreement either until it expires or until it is
openly renegotiated with my therapist. I understand that it is renew-
able at or near the expiration date of ___________________________________ ________ _ (date).
____________________________________ _______ _ __________________________________ _________ _ ____________________________________ _______ _ _____________________________________ ______ _
Signature Date Therapists Signature Date
Note. Adapted from Bongar,1991, and Fremouw, de Perczel, and Ellis,
1990.
74 L. M. Range et al.